odd · 2011-04-07 · odd: a guide for families q 1 oppositional deﬁant disorder: a guide for...

A Guide for Families by the American Academy of Child and

Adolescent Psychiatry

ODD

Oppositional Defiant Disorder

eAACAP on aacap.orgBecause childhood and adolescent mental illnesses are real, common, and treatable

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ODD: A Guide for Families ii

Oppositional Defiant Disorder: A Guide for Families is adapted from the American Academy of Child and Adolescent Psychiatry’s Practice Parameter for the Assessment and Treatment of Children and Adolescents with Oppositional Defiant Disorder. The AACAP Practice Parameter was written to aid clinicians, child and adolescent psychiatrists, physicians, and other healthcare professionals in the diagnosis and treatment of children with ODD. This guide was adapted from the AACAP Practice Parameter in 2009.This publication is protected by copyright and can be reproduced with the permission of the American Academy of Child and Adolescent Psychiatry. ©2009 The American Academy of Child and Adolescent Psychiatry, all rights reseved.

Table of Contents

What Is Oppositional Defiant Disorder (ODD)? 1

How Common Is ODD? 2 What Causes ODD? 3

What Are the Symptoms of ODD? 4

How Is ODD Diagnosed? 5

Can ODD Occur with Other Conditions? 6

Can ODD Be Prevented? 8

How Is ODD Treated? 8

How Long Does Treatment Typically Last? 12

Does ODD Improve over Time? 12

Which Therapies Have Been Shown Not to Work? 13

What Does the Future Hold? 13

References 14



ODD: A Guide for Families 1


What Is Oppositional Defiant Disorder?Oppositional defiant disorder (ODD) is one of a group of behavioral disorders called disruptive be-havior disorders (DBD). These disorders are called this because children who have these disorders tend to disrupt those around them. ODD is one of the more common mental health disorders found in children and adolescents.

Physicians define ODD as a pattern of disobedi-ent, hostile, and defiant behavior directed toward authority figures. Children and adolescents with ODD often rebel, are stubborn, argue with adults, and refuse to obey. They have angry outbursts and have a hard time controlling their temper.

Even the best-behaved children can be uncooperative and hostile at times, particularly adolescents, but those with ODD show a constant pattern of angry and verbally aggressive behaviors, usually aimed at parents and other authority figures.

The most common behaviors that children and adolescents with ODD show are:

A mental health professional is often called upon if these behaviors create a major disturbance at home, at school, or with peers.

critical. This disorder is often accompanied by other serious mental health disorders, and, if left untreated, can develop into conduct disorder (CD), a more serious disruptive behavior disorder. Children with ODD who are not treated





disorder. They may want to wait to start treatment until the child matures to see if he or she will “grow out of it.” Also, it is sometimes difficult to distinguish

during the “terrible twos” and early teen years.

help a child overcome ODD. Treatment also may prevent its progression into a more a serious mental health concern.

Treatment usually consists of a combination of therapies, including behavioral

medication as well.

With treatment, children and adolescents can overcome the behavioral symp-

new ways of coping with stressful situations. Treatment also can help parents

With treatment, children and adolescents with ODD can overcome their difficult behaviors and lead happier, more fulfilling lives.

There is a range of estimates for how many children and adolescents have ODD. Evidence suggests that between 1 and 16 percent of children and adolescents have ODD.1 the prevalence of ODD in preschool children, and estimates cannot be made.2

ODD usually appears in late preschool or early school-aged children. In

boys and girls.3

Although the disorder seems to occur more often in lower socioeconomic





What Causes ODD?

most experts believe that a combination of biologi-

in the development of the disorder.4

Biological FactorsChildren and adolescents are more susceptible to developing ODD if they have:

depression or bipolar disorder)

substance abuse

for reasoning, judgment, and impulse control

Psychological Factors

relationships or process social cues

Social Factors





Most children argue with parents and defy authority from time to time,

associated with ODD also can arise in children who are undergoing a transition, who are under stress, or who are in the midst of a crisis. This

distinguish from expectable stress-related behaviors.5

Children with ODD show an ongoing pattern of extreme negativity, hostility, and defiance that:

principal, coach)

The following behavioral symptoms are associated with ODD:

children whose behavioral symptoms are specifically related to a mood disorder, such as depression or bipolar disorder, are usually not diagnosed with ODD.

Recently, it has been discovered that girls may show the symptoms of ODD differently than boys. Girls with ODD may show their aggressiveness through

lose their temper and argue with adults.6





Diagnosed?While there is no single test that can diagnose ODD, a mental health professional can determine whether a child or adolescent has the disorder by assessing the child’s symptoms and behaviors

diagnosis.

Many parents first call upon the child’s primary care physician for an evaluation. This evaluation typically begins by compiling a medical history and performing a physical examination.

Gathering Information

or other mental health issues that may cause problems with behavior. If the doctor cannot find a physical cause for the symptoms, he or she may refer the child to a child and adolescent psychiatrist or a mental health professional who is trained to diagnose and treat mental illnesses in children and adolescents.

usually diagnoses ODD.

A mental health professional will gather information from parents, teachers, and daycare providers as well as from the child.

Gathering information from as many people as possible will help the doctor determine how often the behaviors occur and where. It also will help the doctor determine how the behaviors affect the different areas of the child’s life.

The mental health professional will determine whether:

or guardians





whether the child or adolescent has developed ODD or is responding to a short-lived, stressful situation.

child’s doctor measure the severity of the behaviors. These tools also may assist

7

been involved in bullying—as either the victim or perpetrator. Involvement in 8

Establishing a Relationship

diagnose. Open communication among the mental health professional and the parents and child can help overcome the difficulties diagnosing this

are unmotivated to change. Also, some parents can become defensive when

the mental health professional as an ally can help.9

Establishing a good relationship with a mental health professional is important to determining whether the child’s behavior is a response to a short-lived situation or transition, ODD, or another serious behavioral condition, such as CD or a mood disorder.

Can ODD Occur with Other Conditions?Many children who are diagnosed with ODD also have other treatable

ODD are:





Research indicates that some children develop the behavioral symptoms of ODD as a way to manage anxiety or uncertainty.10 Anxiety dis-orders and mood disorders are similar to ODD in that they are often a response to uncertainty and an unstable home and school environment.

and anxiety disorder and a mood disorder (such as depression) will occur together.11

Among all conditions that coexist with ODD,

share common symptoms of disruptive behav-

aggressive, have more of the negative behavioral symptoms of ODD, and perform less well in school than those who have ODD alone. These children also tend to have more disruption in their families and with their relationships with authority figures than children who do not have ODD.12

Doctors have found that ODD can be a precursor to CD. CD is a more serious behavioral disorder that can result in destructive antisocial behavior.

While ODD behaviors may start in early preschool years, CD usually appears -

-ing a mood disorder or antisocial personality disorder later in life.13

-ing other more serious mental health issues, treatments exist that can improve

language disorders. Also, treating other mental health and learning conditions that occur along with ODD has been shown to decrease the behavioral symp-toms of ODD.





Can ODD Be Prevented?There is research that shows that early-intervention and school-based programs along with individual therapy can help prevent ODD.14

been shown to help children do well in school and -

health, and other services to low-income children and their families. Young children in this program learn

anger.15 has been shown to help prevent ODD among pre-schoolers.16

vocational training, and help with academics can help reduce disruptive behavior. In addition, school-based programs can be effective in stopping bullying, reducing antisocial behavior, and improving peer relationships.17

Parent-management training programs have proven effective in preventing ODD among all age groups. These programs teach parents how to develop a nurturing and secure relationship with their child and how to set boundaries for unacceptable behavior.18 More information about parent-management training can be found on page nine of this guide.

There is no one-size-fits-all treatment for children and adolescents with ODD. The most effective treatment plans are tailored to the needs and behavioral symptoms of each child. Treatment decisions are typically based on a number of different things, including the child’s age, the severity of the behaviors, and whether the child has a coexisting mental health condition.19





The goals and circumstances of the parents also are important when forming a treatment plan. In many cases, treatment may last several

follow-through by parents as well as by others involved in the child’s care.

Types of TreatmentTreatment usually consists of a combination of:

Parent-Management Training Programs and Family Therapy to teach parents and other family members how to manage the child’s behavior. Parents, family members, and other caregiv-

positive reinforcement and ways to discipline more effectively.

Cognitive Problem-Solving Skills Training to reduce inappropriate behav-iors by teaching the child positive ways of responding to stressful situations.

training teaches them how to see situations and respond appropriately.

Social-Skills Programs and School-Based Programs to teach children and adolescents how to relate more positively to peers and ways to improve their

in a natural environment, such as at the school or in a social group.

Medication may be necessary to help control some of the more distressing symptoms of ODD as well as the symptoms of coexisting conditions, such

a treatment for ODD.

Treatments for Each Age Group--

nation of school-based intervention, parent-management training, and individ-

training has been shown to be the most effective form of treatment.





been shown to greatly improve the behavior of children and adolescents with -

More About Parent-Management Training

ways to reduce the behavioral symptoms of ODD in all age groups.20 Parent-management training teaches parents positive ways to manage their child’s

treatment of choice to prevent disruptive childhood behavior for many mental health professionals.

This approach embraces the following principles:

consistent supervision and discipline

and focus on inappropriate behaviors

Many of the following programs and publications have been noted as positive

Programs

Program Name Age Range Contact Information

Incredible Years Up to 8 years www.IncredibleYears.com

Triple P-Positive Parenting Program Up to 13 years http://www5.triplep.net

Parent-Child Interaction Therapy (PCIT) Up to 8 years www.pcit.org

Center for Collaborative Problem Solving Up to 18 years www.explosivechild.com

The Adolescent Transitions Program (ATP)

11 to 13 years http://cfc.uoregon.edu/atp.htm





Publications

Book Name Age Range Publication Information

The Defiant Child by Douglas Riley, Ph.D. Up to 13 years The Guilford Press

The Explosive Child by R.W. Greene Up to 13 years Harper Paperbacks

The Kazdin Method for Parenting the Defiant Child by Allan E. Kazdin, Ph.D.

Up to 18 years Houghton Mifflin

Parent Management Training by Allan Kazdin Up to 18 years Oxford University Press

Multisystematic Treatment of Antisocial Behavior in Children and Adolescents by Scott Henggeler, Sonja Schoenwald, Charles Borduin, and Melisa Rowland

Up to 18 years The Guilford Press

Helping the Noncompliant Child by Robert McMahon and Rex Forehand

Up to 18 years The Guilford Press

Medication

medication may be a useful part of a comprehensive treatment plan to help

anxiety, and mood disorders.

coexist. When children and adolescents with ODD also have a mood disorder or anxiety, treatment with antidepressants and anti-anxiety medications has been show to help lessen the behavioral symptoms of ODD.21

Early Identification and TreatmentBehaviors that go along with ODD are difficult to change. Therefore, early identification and treatment of ODD give children and adolescents the best chance for success.





Most treatment plans for children and adolescents with ODD last several

respond to therapy, treatment can last many years and may include placement in a treatment center.

A residential treatment center only should be considered for families who are not able to provide therapy at home or at school. In-home services are preferable to residential placement and are often sponsored by state and local child welfare agencies.22

Does ODD Improve over Time?does

found that approximately 67 percent of children diagnosed with ODD who

also show that approximately 30 percent of children who were diagnosed with ODD will go on to develop CD.23

Other studies show that when the behavioral symptoms of ODD begin in early life (preschool or earlier), the child or adolescent will have less chance

times greater for children who were initially diagnosed in preschool.

or bipolar disorder) later in life.

In all age groups, approximately 10 percent of children and adolescents diagnosed with ODD will eventually develop a more lasting personality disorder, such as antisocial personality disorder.24

they receive treatment. Parents who suspect that their child has a behavioral





Experts agree that therapies given in a one-time or short-lived fashion, such as boot camps, tough-love camps, or scare tactics, are not effective for children and adolescents with ODD. In fact, these approaches may do more harm than good. Trying to scare or forcibly coerce children and adolescents into behaving may only reinforce aggressive behavior.25

Children respond best to treatment that rewards positive behavior and teaches

It was once thought that most children would outgrow ODD by adulthood.

can go away over time, and many children outgrow the disorder, some children

later years.

serious behavioral disorder. Of those with CD, almost 40 percent will develop antisocial personality disorder in adulthood.26

Early diagnosis and treatment can help these individuals learn how to cope with stressful situations and manage their behavioral symptoms.

ODD. In fact, for those who receive treatment, many are symptom-free once therapy has concluded and will go on to lead rewarding and happy lives.





References1

defiant and conduct disorder: a review of the past 10 years, part I. J Am Acad Child Adolesc Psychiatry 39:1468-1484.

2 American Psychiatric Association (1980), Diagnostic and Statistical Manual of Mental Disorders, Third Edition Psychiatric Press.

3 Aggression and Antisocial Behavior in Children and Adolescents: Research and Treatment.

4 disorder: a review of the past 10 years, part II. J Am Acad Child Adolesc Psychiatry 41:1275-1293.

5 Assessment and classification of psychopathology in epidemiological research of children 0Y3 years of age: a review of the literature. Eur Child Adolesc Psychiatry 13:337-346.


7 J Am Acad Child Adolesc

Psychiatry 42:1143-1170.8 Olweus D (1994), Bullying at schools: basic facts and effects of a school

based intervention program. J Child Psychol Psychiatry 35:1171-1190.9

into treatment and some variables that may contribute to differential effectiveness. J Family Psychol 10:35-44.

10

anxiety. Clin Child Psychol Psychiatry 7:235-247.11 Aggression and Antisocial Behavior in Children and

Adolescents: Research and Treatment.12 J Child Psychol

Psychiatry 40:57-87.13 American Psychiatric Association (1980), Diagnostic and Statistical Manual

of Mental Disorders, Third Edition Psychiatric Press.







16

program of nurse home visitation: the limiting effects of domestic violence. JAMA 284:1385-1391.



19 Parent Management Training: Treatment for Oppositional, Aggressive, and Antisocial Behavior in Children and Adolescents.

20

J Clin Child Psychol 27:180-189.

21 -

J Am Acad Child Adolesc Psychiatry 41:253-261.

22 Chamberlain P (2003), An overview of the history and development of the multidimensional treatment foster care model and the supporting research. In: Treating Chronic Juvenile Offenders: Advances Made Through the Oregon Multidimensional Treatment Foster Care Model. -berlain P, ed. Washington, DC: American Psychological Association, pp 47-67.


24 J Am Acad Child Adolesc Psychiatry 38:1320-1321.


26 conduct disorder. Psychol Med 22:971-986.




This guide is part of the eAACAP Resource Center on oppositional defiant disorder ODD. The resource center includes information on how and when to

Academy of Child and Adolescent Psychiatry Website at www.aacap.org.



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